Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.

More Than an Inconvenience: Considering Quality of Life When Treating Stress Urinary Incontinence

GOALTo provide urologists, obstetricians/gynecologists, and primary care physicians with information on the most recent developments regarding the treatment of stress urinary incontinence, focusing on quality of life.

TARGET AUDIENCEThis activity is designed for urologists, obstetricians/gynecologists, and primary care physicians.

LEARNING OBJECTIVESThe Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity. At the conclusion of this activity, participants should be able to:

Discuss the available nonsurgical treatments for stress urinary incontinence.

Review the etiology of stress urinary incontinence and its relationship to childbearing.

Describe several methods for measuring quality of life in patients with stress urinary incontinence.

ACCREDITATION STATEMENTThe Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CREDIT DESIGNATION STATEMENTThe Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 category 1 credits toward the AMA Physician's Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in the activity.

The estimated time to complete this educational activity: 2 hours.

Release date: December 15, 2003. Expiration date: December 15, 2005.

DISCLAIMER STATEMENTThe opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of Johns Hopkins University School of Medicine name implies review of educational format design and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

Full Disclosure Policy Affecting CME Activities:As a sponsor accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Director and Participating Faculty reported the following:

PROGRAM DIRECTOR

Geoffrey W. Cundiff, MDAssociate ProfessorDepartment of Gynecology and ObstetricsJohns Hopkins University School of MedicineChair, Department of Obstetrics and GynecologyDirector, Section of Reconstructive Pelvic SurgeryJohns Hopkins Bayview Medical CenterBaltimore, Maryland• Dr Cundiff reports receiving grants and/or research support from Cook Ob/Gyn; and serving as a consultant to Eli Lilly and Company.

PARTICIPATING FACULTY

Michael B. Chancellor, MDProfessorDepartment of UrologyUniversity of PittsburghPittsburgh, Pennsylvania• Dr Chancellor reports receiving grants and/or research support and honoraria from, and serving as a consultant to Eli Lilly and Company.

Nicolette S. Horbach, MD, FACOGAssociate Clinical ProfessorDepartment of Obstetrics and GynecologyGeorge Washington University Medical CenterWashington, DCPracticing PhysicianNorthern Virginia Pelvic Surgery Associates, PCAnnandale, Virginia• Dr Horbach reports receiving grants and/or research support from and serving on the advisory board and speakersÕ bureau for Eli Lilly and Company; and serving on the Board of Trustees for the Berlex Foundation.

Notice:In accordance with the ACCME Standards for Commercial Support, the audience is advised that one or more articles in this continuing medical education activity may contain reference(s) to unlabeled or unapproved uses of drugs or devices. The following faculty members have disclosed that their articles reference the following unlabeled/unapproved uses of drugs or devices:

All other faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Stress urinary incontinence (SUI) is one of the most common problems seen in the clinical practices of gynecologists, urologists, and many primary care physicians. In the United States, between 30% and 40% of women report a history of urinary incontinence; stress incontinence is a component of the condition in a majority of cases.

Although SUI is not a life-threatening condition, it can have a devastating impact on a woman's social life, sexual life, self-esteem, emotional well-being, and overall quality of life. For some patients, the uncontrolled urine leakage becomes a source of profound embarrassment; these patients are often either unwilling to discuss the problem or discuss it only reluctantly. Physicians who care for patients with SUI should demonstrate compassion and reassurance toward these patients. In particular, patients should be assured that urine leakage is neither normal nor an inevitable consequence of aging. Equally important is patients' need for assurance that multiple treatment options exist and can reduce or eliminate urine leakage.

The treatment of SUI is guided primarily by the extent to which the condition affects a patient's quality of life. Making that determination should be a major goal of the initial patient evaluation. Some physicians prefer to use formal quality-of-life questionnaires. Other practitioners incorporate quality-of-life questions into an assessment of bladder health. Still others evaluate SUI and its impact on quality of life as part of the overall medical history. Regardless of method, clinicians should make the quality-of-life assessment an integral component of the initial evaluation of a patient with SUI or suggestive symptoms.

Patients can choose from an array of treatment options spanning the spectrum of aggressiveness. Educating patients about the different options is a key responsibility of the physician in helping the patient to arrive at the best possible decision. No two patients are exactly alike with respect to their tolerance of urine leakage, so the appeal of different treatment options will vary. Some patients may want to begin with the least aggressive options, such as Kegel exercises alone. Some may want to explore noninvasive options, such as biofeedback, perhaps in addition to pelvic floor muscle training. Pessaries will appeal to some patients, but not to others. In urogynecology specialty practices, many patients may present for the specific purpose of discussing surgical options, having already tried less aggressive strategies and found them unacceptable or unsatisfactory.

In reviewing treatment options, the physician should try to ascertain those areas of a patient's life that seem to be most affected by SUI, then try to match the treatment options that appear to be most appropriate for the patient's specific situation. For example, many women do not care to use pessaries on a regular basis but may find the devices both helpful and acceptable as a means of preventing urine loss during exercise.

This issue of Advanced Studies in Medicine provides a clinical practice perspective on the evaluation and management of SUI. The publication includes interviews with two clinicians whose practices include a large population of patients affected by urinary incontinence. The interviews provide insights into the evaluation of patients and the exploration of treatment options. One of these interviews has a specific focus on quality-of-life issues that physicians should recognize and explore in detail with patients who have SUI. Drs Michael B. Chancellor and Naoki Yoshimura review recent developments in noninvasive therapy for SUI. The article includes a look to the future and the availability of the first medical therapy specifically for the treatment of SUI. The dual neurotransmitter reuptake inhibitor duloxetine will likely have a major impact on the nonsurgical management of this condition.

The information provided in this publication is readily applicable in a variety of clinical settings. We are confident that practicing physicians who treat patients with urinary incontinence will find the information both educational and useful in the care of their patients.